Pelvic Pain Assessment Form

Transcription

1 Pelvic Pain Assessment Form Physician: Initial History and Physical Exam Date: Contact Information Name: Birth Date: Chart Number: Phone: Work: Home: Is there an alternate contact if we cannot reach you? Alternate contact phone number: Information About Your Pain Please describe your pain problem: What do you think is causing your pain? What does your family think is causing your pain? Do you think anyone is to blame for your pain? If so, who? Do you think surgery will be necessary? Is there an event that you associate with the onset of pain? If so, what? How long have you had this pain? < 6 months 6 months 1 year 1 2 years > 2 years For each of the symptoms listed below, please bubble in your level of pain over the last month using a 10-point scale: 0 no pain 10 the worst pain imaginable How would you rate your present pain? Pain at ovulation (mid-cycle) Pain level just before period Pain (not cramps) with period Deep pain with intercourse Pain in groin when lifting Pelvic pain lasting hours or days after intercourse Pain when bladder is full Muscle/joint pain Ovarian pain Level of cramps with period Pain after period is over Burning vaginal pain with sex Pain with urination Backache Migraine headache What would be an acceptable level of pain? What is the worst type of pain Kidney stone Bowel obstruction Migraine headache that you have ever experienced? Labor & delivery Current pelvic pain Backache Broken bone Surgery Other November 1999, The International Pelvic Pain Society This document may be freely reproduced and distributed as long as this copyright notice remains intact (205) (800) (if in the U.S.)

2 Demographic Information Are you (check all that apply): Married Widowed Separated Committed Relationship Single Remarried Divorced Who do you live with? Education: Less than 12 years High School graduate Bachelor s degree Postgraduate degree What kind of work are you trained for? What type of work are you doing? Health Habits Do you get regular exercise? Type: What is your diet like? What is your caffeine intake (number per day, include coffee, tea, soft drinks, etc.)? >6 How many cigarettes do you smoke per day? How many years? Have you ever felt the need to cut down on your drinking? Have you ever felt annoyed by criticism of your drinking? Have you ever felt guilty about your drinking, or about something you said or did while you were drinking? Yes Have you ever taken a morning eye-opener drink? No What is your use of recreational drugs? Never used Used in past, but not now Presently using Choose not to answer Heroin Amphetamines Marijuana Barbiturates Cocaine Other Have you ever received treatment for substance abuse? Coping Mechanisms Who are the people you talk to concerning your pain, or during stressful times? Spouse/Partner Relative Support Group Clergy Friend Doctor/Nurse Mental Health Professional I take care of myself How does your partner deal with your pain? Doesn t notice when I m in pain Takes care of me Not applicable Withdraws Feels helpless Distracts me with activities Gets angry What helps your pain? Meditation Relaxation Lying down Music Massage Ice Heating pad Hot bath Pain medication Laxatives/enema Injection TENS unit Bowel movement Emptying bladder Nothing Other What makes your pain worse? Intercourse Orgasm Stress Full meal Bowel movement Full bladder Urination Standing Walking Exercise Time of day Weather Contact with clothing Coughing/sneezing Not related to anything Other Of all of the problems or stresses in your life, how does your pain compare in importance? The most important problem Just one of several/many problems Page , The International Pelvic Pain Society

3 Menses How old were you when your menses started? Are you still having menstrual periods? Answer the following only if you are still having menstrual periods: Periods are: Light Moderate Heavy Bleed through protection How many days between your periods? How many days of menstrual flow? Date of last menses? Do you have any pain with your periods? Does pain start the day flow starts? Starts days before flow starts: Are periods regular? Do you pass any clots in menstrual flow? Bladder Do you experience any of the following: Loss of urine when coughing, sneezing, or laughing? Frequent urination? Need to urinate with little warning? Difficulty passing urine? Frequent bladder infections? Frequency of nighttime urination: or more Volume: Small Medium Large Frequency of daytime urination: 8 or less 9 15 >16 Volume: Small Medium Large Do you still feel full after urination? Bowel Is there discomfort or pain associated with a change in the consistency of the stool (i.e., softer or harder)? Would you say that at least one-fourth (_) of the occasions or days in the last 3 months you have had any of the following (Check all that apply) Fewer than three bowel movements a week (0 2 bowel movements) More than three bowel movements a day (4 or more bowel movements) Hard or lumpy stools Loose or watery stools Straining during a bowel movement Urgency having to rush to the bathroom for a bowel movement Feeling of incomplete emptying after a bowel movement Passing mucus (white material) during a bowel movement Abdominal fullness, bloating, or swelling 1 The Functional Gastrointestinal Disorders, Drossman, et al. Chapter 4, Functional Bowel Disorders and Functional Abdominal Pain Gastrointestinal/Eating Do you have nausea? No With pain Taking medications With eating Other Do you have vomiting? No With pain Taking medications With eating Other Have you ever had an eating disorder such as anorexia or bulimia? Yes No 1999, The International Pelvic Pain Society Page 3

4 Short-Form McGill The words below describe average pain. Place a check mark ( ) in the column which represents the degree to which you feel that type of pain. Please limit yourself to a description of the pain in your pelvic area only. What does your pain feel like? Type None (0) Mild (1) Moderate (2) Severe (3) Throbbing Shooting Stabbing Sharp Cramping Gnawing Hot-Burning Aching Heavy Tender Splitting Tiring-Exhausting Sickening Fearful Punishing-Cruel Melzack, R: The Short-Form McGill Pain Questionnaire, Pain 30: , 1987 Which statement(s) below best describes how you cope with the pain? Check all that apply I count numbers in my head or run a song through my mind I tell myself to be brave and carry on despite the pain I just think of it as some other sensation, such as numbness I tell myself that it really doesn t hurt I pray to God it won t last long I worry all the time about whether it will end I do something active, like household chores or projects I take pain medication I ignore it as best I can Other SF-36 In general, would you say your health is: Excellent Very Good Good Fair Poor Compared to one year ago, how would you rate your health in general now? Much better now than one year ago Somewhat worse now than one year ago Somewhat better now than one year ago Much worse than one year ago About the same as one year ago The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Yes, limited a lot Yes, limited a little No Not limited at all Vigorous activities, such as running, lifting heavy object, participating in strenuous sports Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Lifting or carrying groceries Climbing several flights of stairs Climbing one flight of stairs Bending, kneeling, or stooping Walking more than a mile Walking several blocks Walking one block Bathing or dressing yourself Page , The International Pelvic Pain Society

5 During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities because of your physical health? Cut down the amount of time you spent on your work or other activities Yes No Accomplish less than you would like Yes No Were limited in the kind of work or other activities Yes No Had difficulty performing the work or other activities (for example, it took extra effort) Yes No During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities because of any emotional problems (such as feeling depressed or anxious)? Cut down the amount of time you spent on work or other activities Yes No Accomplished less than you would like Yes No Didn t do work or other activities as carefully as usual Yes No During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friend, neighbors, or groups? Not at all Slightly Moderately Quite a bit Extremely How much bodily pain have you had during the past 4 weeks? None Very mild Mild Moderate Severe Very severe During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks: All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time Did you feel full of pep? Have you been a very nervous person? Have you felt so down in the dumps that nothing could cheer you up? Have you felt calm and peaceful? Did you have a lot of energy? Have you felt downhearted and blue? Did you feel worn out? Have you been a happy person? Did you feel tired? During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.? All of the time Most of the time Some of the time A little of the time None of the time How TRUE or FALSE is each of the following statements for you? Definitely True Mostly True Don t Know Mostly False Definitely False I seem to get sick a little easier than other people I am as healthy as anybody I know I expect my health to get worse My health is excellent 1999, The International Pelvic Pain Society Page 5

6 Personal History What would you like to tell us about your pain that we have not asked? Comments: What types of treatments have you tried in the past for this pain? Acupuncture Homeopathic medicine Physical therapy Anesthesiologist Lupron, Zoladex, Synarel Psychotherapy Anti-seizure medications Massage Rheumatologist Antidepressants Meditation Skin magnets Biofeedback Narcotics Surgery Birth control pills Naturopathic medications TENS unit Danazol (Danocrine) Nerve blocks Trigger point injections Depo-Provera Neurosurgeon Other Family Practitioner Nonprescription medicine Herbal medication Nutrition/diet What physicians or health care providers have evaluated or treated you for chronic pelvic pain? Include all healthcare professionals, whether they were physicians or not. Do you have any objections to me contacting these healthcare providers? Physician/Provider City, State Who is your primary care physician? Please list all surgical procedures you ve had (related to this pain): Year Procedure Surgeon Please list all other surgical procedures: Year Procedure Year Procedure Please list pain medications you ve taken for your pain condition in the past 6 months, and the physicians who prescribed them (use separate page if necessary): Medication Physician Did it help? I have written more medications on a separate page Page , The International Pelvic Pain Society

7 Have you ever been hospitalized for anything besides surgery or childbirth? If yes, explain: Have you had major accidents such as falls or back injury? Have you ever been treated for depression? Treatments: Medication Hospitalization Psychotherapy Birth control method: Nothing Pill Vasectomy Hysterectomy IUD Rhythm Diaphragm Tubal Ligation Condom Other: Is future fertility desired? How many pregnancies have you had? Resulting in (#): Full 9 month Premature Abortions (miscarriage) # living children Any complications during pregnancy, labor, delivery, or post partum period? 4º Episiotomy C-section Post-partum hemorrhaging Vaginal lacerations Forceps Medication for bleeding Other: Has anyone in your family ever had: Fibromyalgia Chronic pelvic pain Scleroderma Endometriosis Lupus Interstitial cystitis Cancer Depression Irritable Bowel Syndrome Recurrent Urinary Tract Infections Place an X at the point of your most intense pain. Shade in all other painful areas. 1999, The International Pelvic Pain Society Page 7

8 Sexual and Physical Abuse History Have you ever been the victim of emotional abuse? This can include being humiliated or insulted. No answer Circle an answer for both as a child and as an adult. 1a. Has anyone ever exposed the sex organs of their body to you when you did not want it? As a child (13 and younger) As an adult (14 and over) Yes No Yes No 1b. Has anyone ever threatened to have sex with you when you did not want it? Yes No Yes No 1c. Has anyone ever touched the sex organs of your body when you did not want Yes No Yes No this? 1d. Has anyone ever made you touch the sex organs of their body when you did not Yes No Yes No want this? 1e. Has anyone ever forced you to have sex when you did not want this? Yes No Yes No 1f. Have you had any other unwanted sexual experiences not mentioned above? If yes, please specify: Yes No Yes No 2 When you were a child (13 or younger), did an older person do the following? a. Hit, kick, or beat you? Never Seldom Occasionally Often b. Seriously threaten your life? Never Seldom Occasionally Often 3 Now that you are an adult (14 or older), has any other adult done the following: a. Hit, kick, or beat you? Never Seldom Occasionally Often b. Seriously threaten your life? Never Seldom Occasionally Often Leserman, J., Drossman, D., Li, Z: The Reliability and Validity of a Sexual and Physical Abuse History Questionnaire in Female Patients with Gastrointestinal Disorders. Behavioral Medicine 21: , 1995 Page , The International Pelvic Pain Society

9 Physical Examination For Physician Use Only Name: Chart Number: Height: Weight: BP: LMP: Temp: Resp: ROS, PFSH Reviewed: Physician Signature General: WNL Walk Facial expression Color Alterations in posture Other NOTE: Mark Not Examined as N/E HEENT WNL Chest WNL Heart WNL Breasts WNL Abdomen Non-tender Incisions Trigger Points Ovarian point tenderness Inguinal tenderness Inguinal bulge Suprapubic tenderness Other Back Non-tender Tenderness Altered ROM Alterations in posture Extremities WNL Edema Varicosities Neuropathy Range of motion Neuropathy Iliohypogastric Ilioinguinal Genitofemoral Pudendal Altered sensation EGBUS/Vagina WNL Lesions Wet prep: Local tenderness: Vaginal mucosa: Posterior fourchette: Discharge: Cultures: GC Chlamydia Fungal Herpes Unimanual pelvic exam WNL Introitus Uterine-cervical junction Urethra Bladder R ureter R inguinal Muscle awareness Rank muscle tenderness on 0-4 scale R obturator L obturator R piriformis L piriformis R pubococcygeus L pubococcygeus Total pelvic floor score Cervix Cervical motion Parametrium Vaginal cuff Cul de sac L ureter L inguinal Clitoral tenderness Patient rates allodynia produced by Q-tip for each circle (0-4). Total Score: 1999, The International Pelvic Pain Society Page 9

10 Bimanual pelvic exam Absent Uterus: Tender Non-tender Position Anterior Posterior Midplane Size Normal Other Contour Regular Irregular Other Consistency Firm Soft Hard Mobility Mobile Hypermobile Fixed Support Well supported Prolapse Adnexae Right Left Absent Absent WNL WNL Tender Tender Fixed Fixed Enlarged cm Enlarged cm Rectovaginal WNL Nodules Guaiac positive Tenderness Mucosal pathology (negative with Not examined quality control) Trigger Points Fibromyalgia Assessment: Diagnostic Plan: Therapeutic Plan: Page , The International Pelvic Pain Society

11 Dear Healthcare Professional: The Research Committee, headed by Deborah Metzger, M.D., Ph.D., along with the Board of Directors of The International Pelvic Pain Society are proud to present this Pelvic Pain Assessment Form for use in the medical community. This form has been developed by clinicians who treat chronic pelvic pain on a daily basis, and is the culmination of two year s effort. We hope that you find it useful. The Pelvic Pain Assessment Form is designed to be printed front and back to yield a total of 10 pages on 5 sheets, for your convenience. It is our desire that this form become a standard in your intake procedures. We solicit your constructive comments. It is only by open communication from the clinician who uses this form consistently that we will improve it. You can phone your comments to the number shown on the form, or us at pelvicpain@aol.com. Sincerely, C. Paul Perry, M.D., Deborah Metzger, M.D., Ph.D. Chairman of the Board of Directors Chairperson, Research Committee